Does shock wave therapy have a future in the treatment of ED?

Urology Times reached out to three urologists (selected randomly and asked them each the following question: Does shock wave therapy have a future in the treatment of ED?

Dr. Reed“The idea is exciting, but there’s always a cost involved. For example, there’s a product that was being injected into Peyronie’s plaque. Initial articles were favorable, but as time passed, we found that patients improved, but hardly anyone was cured. It turned out the treatment was exceedingly costly-about $19,000 if the patient didn’t have insurance-and the patient had to return many times.

Let’s do some dollar engineering on shock wave therapy for ED. What is the cost versus Viagra? Versus a penile implant? Intracorporeal injections? It’s not that it can’t be done, but how much does the patient have to pay for it?

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The basis for it being a cure is not 100% known. It’s believed penis progenitor cells become more effective if they’re subjected to low-intensity shock wave. We aren’t sure if this is purely a vascular effect. Is it a neurogenic effect? Is it a corporeal cellular effect?

We could be very philosophical and say, ‘Who cares? If it’s safe and works-big deal.’

We could do more clinical research or be satisfied with recent multinational studies and say, ‘it’s worked in so many centers in the meta-analysis survey that we should start to make it available in the United States’. According to the meta-analysis, it does work. The question is the cost-benefit ratio. Apparently harmful side effects are not of much consequence. These are the questions that need to be answered.”

Harold Reed, MD 

Bay Harbor Islands, FL

Next: “The ability, potentially, to reestablish healthy arteriogenic and vascular tissue would be a great move forward."

Dr. Tortara“The ability, potentially, to reestablish healthy arteriogenic and vascular tissue would be a great move forward. But it has to be done in a very organized study fashion, so we can tell if we’re actually seeing something happen.

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We need a controlled study with, say, 1,000 men treated with the machine and 1,000 men treated with a sham machine. It would be a randomized, double-blind study, then we would see if shock wave therapy actually works.

It sounds interesting. It seems like it works in the European studies, but those were meta-analyses, which can give you misleading information. You can’t always draw conclusions because it only takes one bad study to affect the outcomes.

I don’t have any concerns, in the sense that you’re dealing with a non-invasive method. You’re dealing with men who already can’t get erections, and they’ve already used the sound waves on non-human tissue to show the damage it can do. Preliminary studies showed some trauma in the tissue that led to new vascularization and new blood vessel growth. So, we have some baseline data, and it doesn’t look like there’s high potential for injury to the patient.

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I’m sure initially the cost will be high, but it’s the kind of technology we’re used to and eventually the cost could be reasonable, especially when a Viagra tablet costs $60 per pill.”

Frank Tortora, MD 

Cary, NC

Next: “It’s an intriguing therapy"

Dr. Broghammer“It’s an intriguing therapy and data from randomized trials and meta-analyses published in the last couple years seem to support it.

Personally, I would want to drill down, specifically, on the ideal patient; there are multiple causes for erectile dysfunction, so how would you identify appropriate patients for this therapy? I’d also like to see more patients in those studies before it’s ready for prime time, at least in my practice.

The concept seems counterintuitive. We don’t use this sort of treatment in other vascular disorders, whether it’s heart disease, carotid arteries, or peripheral vascular disease. From that perspective, I’m not sure how it applies to the penis.

The injury it causes may promote neovascularization, but I’m concerned about problem events in the vessels themselves. What if it breaks off plaque and causes downstream obstruction of the artery? I’d like to see more functional outcomes to see the downsides and the risks to it.

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My concerns are its efficaciousness and how long it lasts. I haven’t seen a lot of studies showing its effectiveness years down the road. 

A cure would be appealing; I’m just skeptical of long-term effects. The other question: Are we impacting patients’ lives in terms of reducing risk factors in men’s health, like diabetes and high blood pressure? Are we having patients modify their lifestyles, like smoking cessation and better control of diabetes, to prevent future damage to the vascularity, or are we simply treating with the shock wave?

We really need a multicenter study, then long-term surveillance in patients who have undergone the therapy and answers to whether it’s durable or transient.”

Joshua Broghammer, MD 

Kansas City, KS

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